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A report prepared by

The Center for Public Health and Health Policy at The University of Connecticut Health Center and The University of Connecticut, Storrs

June 2008

The Center for Public Health and Health Policy (CPHHP) was established as a University-wide Center in 2004. It serves as “the central organizing and implementing force in public health for teaching, research, and service activities…that…will enable the University to speak with one voice to any and all interested agencies and other constituencies regarding established or new needs in public health education and research of significance for all of our citizens throughout the State and the region.” (President Philip Austin, November, 2005)

On the Cover: Hygeia, Greek goddess of prevention

Prepared By:

Brian L. Benson, MPP Eileen Storey, MD, MPH Charles G. Huntington, III, PA, MPH Mary U. Eberle, JD Ann M. Ferris, PhD, RD

© June 2008, University of Connecticut

The Economic Impact of Prevention

Executive Summary From 2005 to 2006, U.S. health care spending increased 6.7 percent to $2.1 trillion, or $7026 per person. The most recent state estimates show that in 2004, total health care spending in Connecticut was over $22 billion or $6,344 per person, which at that time was 20 percent higher than the national average. Health care spending in the United States is expected to continue to increase during the next decade, and is estimated to reach $4.3 trillion in 2017, or $13,101 per person. If health care spending in Connecticut continues to exceed national estimates by 20 percent, it could reach $26.4 billion in 2017, or $15,721 per person.

While U.S. per capita health spending is the highest in the world, U.S. health outcomes lag behind those of most other industrialized countries. High health care costs in the face of suboptimal health outcomes suggest that the U.S. is getting poor value for its health care dollar. In contrast, a large body of evidence from a wide variety of sources suggests that investments in prevention produce value in health care spending, increased productivity and improved quality of life. Evidence clearly demonstrates the In an effort to contribute to current dialogue regarding health benefits and health system reform, the Center for Public Health and Health Policy at the University of Connecticut reviewed the economic value of existing evidence on the effectiveness and cost-effectiveness of prevention. The disease and injury prevention and health promotion. In impact of benefit economic terms, the Center’s task was to elucidate the nature and extent of the evidence that demonstrates cost- and value is effectiveness of disease and injury prevention programs and greatest when clinical prevention services. prevention is

Key Findings: implemented at the earliest • Evidence clearly demonstrates the health benefits and opportunity. economic value of prevention. The impact of benefit and value is greatest when prevention is implemented at the earliest opportunity.

• Primary prevention forestalls or blocks the onset of disease, thereby avoiding or delaying the costs associated with treatment and lost function. For example, immunizations reduce the transmission of infectious diseases and thereby reduce the costs associated

i with treatment and other economic effects (e.g., reduced wages and productivity) of acquired disease.

• Secondary prevention takes the form of the early detection of asymptomatic diseases through screening. Early detection enables the interruption of the disease process at a point when treatment costs are less, when health and functioning can be preserved or more fully restored, and when related costs such as work absence are less. For example, cholesterol screening identifies asymptomatic persons at increased risk of coronary artery disease, which when untreated leads to significant increases in preventable death, disability, and medical expenditures.

• Tertiary prevention services intervene when a disease or injury has already occurred. Tertiary prevention seeks to limit relatively expensive hospitalizations and improve quality of life through the effective management of symptoms. Disease management programs have emerged as the cornerstone of tertiary prevention.

• Besides the traditional three dimensions of primary, secondary, and tertiary, prevention and health promotion interventions occur across a risk-reduction continuum that includes individualized interventions, clinician-directed services, and community- and employer- based strategies. For example, primary prevention of type II diabetes might include a built environment that facilitates walking, biking, and other safe opportunities for exercise in the community, and individualized and workplace exercise At the individual level and diet programs. The secondary prevention entails making prevention of diabetes might include healthy choices as a result of screening for early detection and diet and exercise counseling to delay onset. education and an Tertiary prevention might include a environment that influences disease management program to and supports good choices. prevent serious complications of diabetes such as blindness and amputation.

• At the individual level prevention entails making healthy choices as a result of education and an environment that influences and supports good choices. Smoking, poor diet coupled with physical inactivity, and alcohol consumption were the leading actual causes of mortality in the United States in 1990 and again in 2000 and are significant drivers of health care utilization. Prevention programs and interventions are effective in supporting and encouraging healthy behaviors.

• Health care and health spending are not distributed uniformly in Connecticut, resulting in severe health disparities by race/ethnicity, income, education, and geographic location. Maintaining or improving the health of all state residents in coming years will require investments in prevention, particularly at the population level that encourage and support healthy behaviors, reverse or slow growth in rates of chronic diseases, and improve service delivery for underserved populations. Specific strategies need to be

ii developed that effectively deliver preventive services to, improve the health of, and support healthy behaviors among, minority populations.

• Connecticut neither maximizes investment in prevention nor receives optimal benefits of prevention for state-covered populations (e.g., state employees, persons covered by Medicaid, and the uncompensated care pool). Improved delivery of prevention programs and services is possible despite existing regulatory and structural restrictions.

Throughout the course of the Center’s investigation, many questions arose. Most notably:

• What is the impact of growing burdens of chronic disease on health spending? • Which characteristics of our health system constitute barriers to the implementation of prevention programs? • What are the implications of universal health insurance coverage for prevention and vice versa?

Chronic disease Chronic diseases have emerged as the major drivers of health care costs, as well as associated economic losses. The explosion in the rates of chronic diseases that intensify treatment levels and escalate spending is in large part due to unhealthy behaviors. Medical advances have also increased survival into old age resulting in many elderly people living with multiple chronic conditions. However, many chronic diseases are amenable to primary, secondary, and tertiary prevention services. The burden of chronic diseases such as heart disease, cancer, depression, hypertension, and type II diabetes could be greatly reduced if proven clinical and community preventive measures were fully implemented.

Structural frameworks The Center’s analysis of the cost- effectiveness of prevention services is Controlling the growth of future driven by three fundamental health costs rests on the ability to characteristics of the U.S. health care system. First, the U.S. lags behind prevent proactively, detect early, most other developed nations in regard and manage well the diseases that to the effectiveness and efficiency of its drive health care costs. health care system. Second, significant disparities in specific measures of health, life expectancy, and quality of life exist along the lines of gender, race and ethnicity, income, education, geography, disability status, and sexual orientation. And, third, the flow of resources in the U.S. health care system is heavily skewed toward the diagnosis and treatment of disease and injury. The market forces that drive the current health care system produce medical care rather than healthy individuals and populations.

iii Implications of universal health insurance Prevention is an integral part of the discussion as the United States moves toward universal health insurance. Current efforts in Connecticut to address the lack of coverage for over 350,000 residents create both an opportunity and a need to invest in a health system with a focus on prevention. Only a health system that enhances access to proven disease prevention and health promotion services has the potential to control costs and improve health outcomes in the long term.

As the evidence described in this report indicates, getting the most value for the U.S. health care dollar requires shifting the focus from medical treatment to population-based prevention. Controlling the growth of future health costs rests on the ability to prevent proactively, detect early, and manage well the diseases that drive health care costs.

Currently, prevention strategies that have proven effectiveness and provide value for the dollar are implemented at suboptimal levels. Thus, ample opportunities for improvement exist within the current U.S. health care system, even while working toward comprehensive reforms that support full implementation of prevention.

iv

Table of Contents

Executive Summary...... i

Table of Contents ...... v

Tables and Figures ...... vi

Introduction...... 1

Economic Methods ...... 3

Prevention: Constructs and Cost-Effectiveness...... 4

Primary Prevention ...... 4 Secondary Prevention...... 8 Tertiary Prevention ...... 10

The Nation and the State of Connecticut: Costs, Challenges, and Opportunities ...... 12

Behavior and lifestyle factors ...... 12 Chronic disease ...... 13 Health disparities ...... 14 Prevention benefits to the state and other employers ...... 15

Conclusion...... 17

Appendices

Appendix I: Healthy People 2010 ...... 18 Appendix II: Healthy Connecticut 2000 ...... 19 Appendix III: U.S. Task Force on Community Preventive Services...... 20 Appendix IV: The U.S. Preventive Services Task Force...... 22 Appendix V: Economic Methods Glossary ...... 23

Notes ...... 25

v

Tables and Figures

Figure 1: Cost-effectiveness Ratio...... 4

Table 1: Primary Prevention Interventions...... 7

Table 2: Secondary Prevention Interventions ...... 9

Table 3: Tertiary Prevention Interventions...... 11

Table A1: Healthy Connecticut 2000 Priority Areas...... 19

vi The Economic Impact of Prevention

Introduction Health can be viewed from the perspective of the individual or the population. Individual health is typically measured in terms of the absence of disease or illness, while population health is generally measured in terms of life expectancy, functional capacity, and prevalence of disease in a group or community. Individual health services occur through diagnosis and treatment of individual patients, while population health services seek improvement in the conditions necessary for health for everyone in the community.1 Population-based prevention, a prevention strategy in the vein of traditional public health, attempts to remove the underlying causes of disease, i.e., attempting to control the determinants of incidence and shift the whole distribution of exposure in a favorable direction.2

Prevention has become an increasingly important concern in light of the reemergence of universal health insurance as a priority issue among state and federal policymakers. Any expansion of health insurance Current efforts in coverage requires overcoming difficult obstacles in the Connecticut to address current health care marketplace, including increasing the lack of coverage for health care costs and a shrinking base of employer- sponsored health insurance. Current efforts in over 350,000 residents Connecticut to address the lack of coverage for over create an opportunity 350,000 residents create an opportunity to invest in a to invest in a health health system with a focus on prevention, i.e., a health system that enhances access to proven disease system with a focus on prevention and health promotion services. Such a prevention. system has the potential to cost less and improve health outcomes in the long term.

The United States has long recognized the importance of population-based prevention at the federal level. The federal government’s recent leadership in prevention is most notably associated with its Healthy People initiative. Healthy People was initiated by the U.S. Department of Health and Human Services (HHS) to identify opportunities to improve the health of all Americans through prevention. HHS first published Healthy People 2000 in 1990 and then followed with Healthy People 2010 in 2000. The goals of Healthy People 2010 are to increase the quality and years of healthy life and to eliminate health disparities. These goals are supported by 467 specific objectives in 28 focus areas that range from diseases (e.g., cancer, diabetes) to behaviors and lifestyle factors (e.g., tobacco use, physical fitness) to specific components of the health system (e.g., public health infrastructure).3

A midcourse review published in 2006 found that 59 percent of the objectives had been fully or partially met, but for 26 percent of the objectives no change or negative progress had occurred.4 The areas of poorest performance include substance abuse, nutrition and overweight, mental health and mental disorders, and chronic kidney disease. While some progress has been achieved in some objectives related to increasing quality and years of healthy life, progress has not occurred in eliminating health disparities.5 Continued commitment to prevention and health promotion at the federal level is required to meet all Healthy People 2010 goals and objectives, but evidence to date suggests that achieving progress in all focus areas and reducing health

1 The Economic Impact of Prevention

disparities may require using different, more effective, and perhaps as yet undeveloped preventive strategies and programs.

The State of Connecticut followed the federal government’s lead with the launch of Healthy Connecticut 2000 in 1994. It applies some of the national goals in Healthy People 2000 to Connecticut’s population based on nineteen priority areas, many of which are amenable to disease prevention and health promotion.6 The priority areas are grouped under four headings, which include Health Promotion, Health Protection, Preventive Services, and Surveillance and Data Systems. The Healthy Connecticut 2000 Final Report, published in 2005, documents improvement in many of the priority areas and recommends increased public health efforts in others, including tobacco use; diet, physical activity, and overweight; infectious and vaccine- preventable diseases; low birth weight; and environmental health.

Despite federal and state recognition of the importance of prevention and the documented progress toward many of the goals and objectives in Healthy People 2010 and Healthy Connecticut 2000, the investment in prevention and health promotion in the United States and in Connecticut pales in comparison to the expenditures for diagnostic and treatment services. Health spending on treatment claims 90 percent of our health care dollar while less than 2 percent focuses on population-based prevention.7 The lack of investment in disease prevention is reflected in the fact that only 49 percent of adults in the U.S. received recommended screening and preventive care in 2002 despite well-documented benefits,8 and life expectancy decline relative to the national average in areas with high rates of chronic diseases related to smoking, overweight and obesity, diabetes, and high blood pressure.9

The United States has led the world in total health expenditures per capita and in the rate of health spending as a percentage of Gross Domestic Product (GDP) during the past two decades.10 Despite this level of health spending, the United States ranks in the lower third of developed nations for most indicators of health status,11 and last among nineteen industrialized countries in deaths that would have been avoided in the presence of effective health care.12 The available evidence indicates that the United States is getting poor value for its health care spending.

Compared to other states, Connecticut places a particularly low priority on prevention. State per capita spending on population health interventions (including prevention of epidemics, protection against environmental hazards, injury prevention, promotion of disease control, encouragement of healthy lifestyles, disaster preparation, disaster response, and health infrastructure) ranks 44th in the country.13 In contrast, Connecticut’s performance on various measures of population health compares favorably with other states, although state comparisons in population health occur in the context of the relatively poor national health status of the United States. Additionally, buried in Connecticut’s relatively high health status measures are some of the most extreme variations; i.e., health disparities. Thus, even for states with relatively good health status measures, substantial opportunities exist for improved health status and cost savings from a greater investment in prevention.

Despite clear evidence that prevention interventions forestall or block the onset of disease and thereby increase quality of life and lifespan, the extant disease prevention and health promotion efforts lack the urgency of more emergent medical needs. While preventive services are not

2 The Economic Impact of Prevention

without their own costs, many preventive services yield potential cost savings. For example, in 2004 the National Committee for Quality Assurance (NCQA) identified 21,000 excess cases of osteoporosis-related fractures, 20,000 excess cases of late-stage colorectal cancer, and 7,600 excess cases of late-stage breast cancer that could have been averted with timely preventive care. Doing so would have saved $485.2 million in excess medical expenses.14

This paper identifies preventive interventions that are both effective in improving health status and quality of life and produce value for the dollar. Many of the interventions also provide opportunities to reduce lifetime health costs. This paper is intended to inform decisions regarding the allocation of resources toward health services that are effective as well as cost- effective. The potential impact of increased investment in prevention for the State of Connecticut is highlighted, particularly for populations that generally rely on the state for health care and health insurance, i.e., state employees and persons covered by Medicaid. Evidence is presented to support the transformation of our health system into one that prioritizes population-based prevention wherever it occurs, including individualized interventions, clinician-directed activities, community-based strategies, and population level approaches.

Economic Methods Effectiveness studies, simulation modeling, and economic evaluations provide systematic and evidence-based frameworks for making decisions about funding for prevention interventions.15 Effectiveness studies examine whether a specific intervention works in a community setting or practice environment, as opposed to bench research or a clinical study. Simulation modeling is a well-accepted alternative to effectiveness studies when data are not available from long-term intervention studies. Economic evaluations summarize the expected benefits, harms, and costs of implementing a specific strategy. When properly used in the health sphere, economic studies complement the evidence on the effectiveness of interventions.

Four main methods are used in economic evaluation of health programs: cost analysis, cost- effectiveness analysis, cost-utility analysis, and cost-benefit analysis. In cost-analysis, the costs of a program or intervention are identified or estimated, which allows calculation of unit costs, but does not provide information about program effectiveness or a direct measure of benefits. Cost- benefit analyses compare program costs and benefits over a period of time and are expressed in dollars as an aid in determining the best resource investments; however, there are practical and ethical issues in placing monetary value on health outcomes, including human life, that limit its widespread use. Thus, cost-effectiveness analysis and cost-utility analysis have become the predominant methods of economic evaluation used in health (including prevention) studies because they provide information on program costs and effectiveness/benefits but do not require health outcomes to be valued in monetary units.

Cost-effectiveness analysis and cost-utility analysis use a ratio that compares the costs and financial benefits of the intervention, including the costs of side effects and the savings from avoided illness and disability, to the health effects of the intervention, which is usually expressed as either a life year gained or saved (for cost-effectiveness analysis) or a quality-adjusted life year (QALY) gained or saved (for cost-utility analysis). 16,17,18 A quality-adjusted life year takes into account factors such as pain and disability. Both medical and non-medical costs (e.g., lost

3 The Economic Impact of Prevention

productivity, transportation) associated with the intervention or illness are included in the ratio. In performing cost-effectiveness analysis and cost-utility analysis most researchers use discounting to account for the time value of money (inflation). 19 Comparisons of cost- effectiveness/utility ratios for different services are used to determine which services require the fewest dollars to produce the same unit of health. The lower the number, the more cost-effective the intervention. Figure 1: Cost-Effectiveness Ratio

CE = ___Cost with intervention – Cost without intervention___ Outcome with intervention – Outcome without intervention

A medical intervention is considered cost-effective when the intervention provides a health benefit at an acceptable cost. While the idea of “acceptable cost” is debated, the commonly accepted range of values for determining the cost-effectiveness of an intervention is $50,000 to $100,000 per life year or QALY gained. Historically, an intervention estimated at $50,000 or less per life year/QALY gained is considered a bargain, less than $100,000 is considered reasonable, and over $100,000 is considered a poor value. While competent researchers account for inflation in their estimates when possible, the generally-accepted cost-effectiveness thresholds have not increased in 25 years,20, 21 thus they should be considered conservative estimates.

Prevention: Constructs and Cost-Effectiveness Prevention is commonly divided into three dimensions: primary, secondary, and tertiary. Each dimension is essential to the health of populations and individuals. Primary prevention largely takes place in the societal domain, secondary prevention within health care and in other institutions such as schools and workplaces, and tertiary prevention is a component of good clinical care. The distinct boundaries of the traditional dimensions of prevention are blurring as medical practices and public/population health strategies evolve. Prevention and risk reduction are taking place across a continuum that includes individuals, communities, and clinical settings. However, separation of prevention into its traditional dimensions helps in understanding and organizing discussions of the effectiveness and cost-effectiveness of particular preventive interventions.

Primary prevention: Primary prevention Primary prevention seeks to avert the occurrence of a seeks to avert the disease or injury. It includes clean water and air, safe occurrence of a disease and nutritious food, safe home and work environments, or injury. Many of the violence-free communities, safe transportation systems, and a public educated in the pursuit of good health. most cost-effective Many of the most cost-effective primary prevention primary prevention interventions occur at the population level. interventions occur at the population level.

4 The Economic Impact of Prevention

Several very important primary prevention activities occur in health care settings and are commonly provided by primary care providers. For example, immunizations prevent a host of deadly or debilitating diseases, and it could be argued that the development of vaccines and immunizations are some of the most important medical advances in human history. Primary care providers are well-positioned to provide referrals and to connect patients to primary prevention resources available in the community, and evidence shows a positive association between primary care and the provision of preventive services.22

Promoting healthy behaviors is an important component of primary prevention. Public information campaigns that encourage people to be physically active, avoid tobacco, and consume nutritious foods play vital roles in preventing disease and improving quality of life. Health promotion is also effective in community, school, and health care settings. For example, since 1991, U.S. teenage pregnancy, abortion, and birth rates have declined steadily in every age and racial/ethnic group. Teen pregnancy rates (per 1,000) in Connecticut dropped from 107 (per 1,000 teens) in 1988 to 70 (per 1,000 teens) in 2000.23 The majority of this decrease is the result of improved contraceptive use,24 which resulted from health promotion activities.

Economic and health policies also play a role in primary prevention. For example, the federal food stamp program has increased access to healthy food and provided consumer education to support healthy diets. The Special Supplemental Nutrition Program for Women, Infants, and Children, commonly known as the WIC program, is also oriented toward prevention. During critical periods of child development, WIC provides supplemental diets with nutritious foods, offers nutrition education and counseling, and provides referrals to health care providers and social services agencies, through which medical and developmental problems can be prevented, addressed at an early stage, or treated.

Another example of an economic policy with primary Environmental health prevention implications occurred in Poland in the 1990s. A sharp reduction in heart disease deaths factors play a central between 1991 and 1998 was attributed to a shift in role in human consumption from animal (saturated) fats to development, health vegetable (unsaturated) fats and increased consumption of fruits and vegetables after status, quality of life, government subsidies for purchases of foods derived and the safety of from animal sources ended.25 communities.

Environmental health factors play a central role in

human development, health status, quality of life, and the safety of communities. Some of the Primary prevention components of environmental health include interventions in the community design to encourage physical activity and workplace reduce the reductions in environmental hazards such as exposure to toxic substances. For example, the elimination of likelihood of death, lead in paint, gasoline, and other consumer products injury, or illness. has reduced lead exposure among infants and children and resulted in healthier neurological development.26

5 The Economic Impact of Prevention

Primary prevention interventions in the workplace reduce the likelihood of death, injury, or illness. For example, ergonomic interventions reduce the likelihood of musculoskeletal disorders caused by repetitive motions or poor design, and the use of less toxic materials, engineering controls, or personal protection such as respirators reduces exposure to harmful chemicals and gases. Noise reduction helps prevent hearing loss. Worksite stress reduction programs and improvements in work organization contribute to the prevention of hypertension, heart disease, and mental health problems.

Table 1 lists selected primary prevention interventions that have been proven to be both effective in preventing or minimizing disease and cost-effective (estimated cost of ≤ $100,000 per life year/QALY gained or less).

Appendix III provides further information and additional examples of primary prevention effectiveness studies and economic evaluations. It includes a discussion of the U.S. Task Force on Community Preventive Services and The Guide to Community Preventive Services: What Works to Promote Health?

6

Table 1. Primary Prevention Interventions Examples with Demonstrated Evidence of Effectiveness and Cost-Effectiveness

Intervention Study population(s) Health effects/benefits Community water fluoridation Children 4-17 years old Prevents dental caries.27,28,29,30,31 Early childhood development Children 3 years old from Improved cognitive and social outcomes which often lead to improved long- programs low income families term health.32 Reducing environmental Children Reduction in lead poisoning, asthma, cancer, and developmental disabilities.33 pollutants Maternal health and safe Adults and adolescents Prenatal and delivery care, postpartum care, prevention of unintended motherhood interventions; family pregnancies.34 planning Multi-component workplace Employees Reductions in health risk factors and absenteeism; increased work health promotion program performance.35 Workplace fitness facilities Employees Reduced disability and health care costs.36 Ergonomic interventions Employed Reduced workplace accidents, injuries, illnesses.37,38 Immunizations Children, elderly Infectious disease prevention.39,40,41,42,43

7 Reducing alcohol-impaired driving Alcohol-impaired drivers Accidents/trauma reduction, medical cost savings, averted productivity losses, through sobriety checkpoints and pain, and suffering.44,45,46,47 mass media campaigns Increasing excise taxes on tobacco Current and potential Tobacco free lifestyles.48 products tobacco users, especially teens Health education about smoking Adolescents Tobacco free lifestyles.49 Smoking bans and restrictions; Current and potential Medical cost savings, reduced morbidity and mortality, averted smoking- environmental tobacco smoke tobacco users; general related fires, productivity gains.50 restrictions public Prenatal and infancy nurse home Pregnant, low-income Improvement in a wide range of maternal and child health outcomes, visitation women and their children including reduced smoking and improved diets during pregnancy, fewer preterm deliveries, higher mean birthweights, reduction in child abuse and neglect, fewer child emergency room visits.51

The Economic Impact of Prevention

Secondary prevention: Secondary prevention refers to the early detection of a disease process and intervention to reverse or retard its progression.52 Secondary prevention occurs through community screening programs that seek to test large groups of people or as part of individual health examinations given by health professionals. Many secondary prevention activities are effective in identifying health problems that could cause considerable morbidity and mortality if left untreated. For example, blood pressure screening and evaluating lipid profiles detect hypertension and hyperlipidemia, which, when treated, limit progression towards heart disease.53

In a highly functioning health system, primary care providers are crucial to the delivery of secondary prevention services. Many of the most beneficial and cost-effective secondary prevention interventions are delivered via primary care. Interventions generally take the form of counseling (e.g., to avoid tobacco use or increase exercise) or screening for asymptomatic disease such as cancer or high blood pressure.54 Despite the importance of primary care for effective delivery of prevention services, the current healthcare market undervalues primary care.55 Renewed emphasis should be placed on models of practice and reimbursement (e.g., the medical home) that support the effective delivery of primary care.

The United States Preventive Services Task Force (USPSTF) is the principal federal source of information about secondary prevention. The USPSTF, initially convened in 1984, resulted from the adoption of a comprehensive prevention policy by the U.S. Department of Health, Education, and Welfare. The USPSTF conducts rigorous, impartial assessments of the scientific evidence regarding the effectiveness of a broad range of clinical preventive services, including screening, counseling, and preventive medications. Results are published and updated periodically to reflect recent research, emerging evidence, and disease trends.56

According to expert analysis, the highest priority preventive services recommended by the USPSTF are aspirin use by high-risk adults, immunizing children, and tobacco-use screening and brief intervention.57 Aspirin use can prevent myocardial infarction (heart attack) for persons at risk for coronary heart disease. Tobacco-use screening and intervention helps people quit smoking, thus reducing risk of developing tobacco-use related diseases such as heart disease, lung cancer, and chronic obstructive pulmonary disease. These services generate the highest health impact (measured as clinically preventable burden) and are the most cost-effective.58

Please see Appendix IV for additional Secondary prevention refers to the information about the activities and early detection of a disease process recommendations of the USPSTF. and intervention to reverse or retard Table 2 lists selected secondary its progression. prevention interventions that have been proven to be both effective in Many of the most beneficial and preventing or minimizing disease and cost-effective (estimated cost of cost-effective secondary prevention ≤ $100,000 per life year/QALY gained interventions are delivered via or less). primary care. 8

Table 2. Secondary Prevention Interventions Examples with Demonstrated Evidence of Effectiveness and Cost-Effectiveness59

Intervention Target population Health effects/benefits Men ≥ 40, women ≥50, others Decreases incidence of coronary heart disease events in adults who Aspirin prophylaxis at increased risk are at increased risk for coronary heart disease. Tobacco use screening and brief intervention All adults Increases tobacco abstinence rates. Reducing out-of-pocket costs for effective smoking cessation therapies; multi-component Smokers Tobacco free lifestyles.60,61 interventions with client telephone support Colorectal cancer screening Adults age ≥50 Reduces mortality from colorectal cancer. Detection of hypertension. Treatment of hypertension Hypertension (high blood pressure) screening All adults substantially decreases the incidence of cardiovascular events. Identify adults whose levels or patterns of alcohol consumption place them at risk for increased morbidity and mortality. Problem drinking screening and brief counseling All adults Reductions in alcohol consumption that are sustained over 6- to

9 12-month periods or longer. All women who have been Cervical cancer screening sexually active and have a Reduces incidence of and mortality from cervical cancer. cervix Identify asymptomatic persons at increased risk of coronary heart Cholesterol screening Men ≥35 and women ≥45 disease. Diet and lipid-lowering drug therapy substantially decreases incidence of coronary heart disease. Breast cancer screening Women age 40+ Reduces mortality from breast cancer. Breast cancer screening (mammography) Women age 65+ Reduces mortality from breast cancer.62 Sexually active women ≤25; Chlamydia screening Reduces incidence of pelvic inflammatory disease (PID). older women at increased risk Screening tests identify strabismus, amblyopia, and refractive error in children with these conditions and leads to improved visual Vision screening Children aged < 5 years acuity. Treatment of strabismus and amblyopia can improve visual acuity and reduce long-term amblyopia. Visual Screening for Malignant Melanoma Adults age 50+ Increases life expectancy and quality-adjusted life expectancy.63

Outpatients with fever or 64 Testing for Primary HIV Infection Early detection of HIV and cases avoided in sexual partners. other viral symptoms Neonatal screening for Cystic Fibrosis Neonates Improved quality of life and life expectancy for persons with CF.65

The Economic Impact of Prevention

Tertiary prevention: The two main categories of tertiary prevention are disability limitation and rehabilitation.66 Disability limitation seeks to halt the progression and limit the effects of symptoms caused by a disease or injury. Rehabilitation reduces social disability by both strengthening remaining functions and helping the patient learn to function in alternative ways.

As is the case for primary and secondary prevention, primary care providers have an important role in the delivery of tertiary prevention services. In Chronic disease particular, primary care providers have proven to be management is a cornerstone a critical factor in effective management of chronic of tertiary prevention. disease, reducing complications and costs. For example, a study of urban children with asthma showed that children with a greater number of asthma-related primary care visits were less likely to have asthma-related emergency department visits.67

Chronic disease management in the clinical setting is a special type of disability limitation strategy and is a cornerstone of tertiary prevention. It aims to improve quality of life and improve health and functioning while simultaneously preventing costly hospitalizations for persons with chronic diseases, such as diabetes, congestive heart failure, and asthma.68-69 In recent years disease management programs have moved beyond the clinical setting. For example, asthma management can be significantly enhanced through engagement of school nurses, and hypertension control can be improved through worksite interventions such as blood pressure monitoring, exercise programs, and healthy food choices in cafeterias.

Many disease management programs conducted independently by insurance companies are reaching plateaus in terms of effectiveness and cost savings. Many of these same programs have little interaction and coordination with primary care providers. Chronic disease management programs that include more coordination between insurers and primary care providers and that utilize innovative approaches to patient education and support for behavior change may result in better management of chronic disease and improved health outcomes.

Table 3 lists selected tertiary prevention interventions that have been proven to be both effective in managing or minimizing disease and cost-effective (estimated cost of ≤ $100,000 per life year/QALY gained or less).

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Table 3. Tertiary Prevention Interventions Examples with Demonstrated Evidence of Effectiveness and Cost-Effectiveness

Intervention Target population Program components Health effects/economic benefits Chronic Disease Persons with asthma Patient education and medication Significantly reduced use of emergency health management management consistent with national care services and considerable health cost guidelines. savings.70,71 Persons with congestive Multidimensional program including Reduced medical costs compared to previous heart failure patient education, monitoring, and year while costs increased for control group physician notification. compared to previous year.72 Children with newly Education program for self-management Mean glycated hemoglobin (GHb) levels were diagnosed type I of diabetes in the home. 10% lower for the intervention group at 24 and diabetes 36 months. Costs of the intervention program did not differ significantly from traditional care.73 Disease management Persons with Reduced copayments for medications Increased medication adherence above the

11 with reduced hypertension, diabetes, prescribed to control a chronic condition effects of a disease management program copayments for high cholesterol, or in the context of a disease management alone.74 selected classes of asthma program. Drug categories include ACE medications inhibitors/ARBs, beta-blockers, several diabetes drugs, statins, and steroids. Combination Persons who have had a Combination pharmacotherapy at no cost Greatly reduces cardiac events, including heart pharmacotherapy heart attack to participants. attacks.75 (aspirin, beta- blockers, ACE inhibitors, statins) ACE inhibitors Medicare beneficiaries ACE inhibitors at no cost to participants. Extends life and reduces Medicare costs.76 with diabetes

The Economic Impact of Prevention

The Nation and the State of Connecticut: Costs, Challenges, and Opportunities

Behavior and lifestyle factors While many public health and clinical guidelines emphasize the importance of healthy behaviors, only three percent of Americans follow all four healthy lifestyle recommendations (nonsmoking, healthy weight, consuming five or more fruits and vegetables per day, and regular physical activity).77 Smoking, poor diet coupled with physical inactivity, and alcohol consumption were the leading “actual” causes of mortality in the United States in 1990 and again in 2000.78 For example, overweight and obesity (conditions exacerbated by poor diet and physical inactivity) is estimated to cause 14-20 percent of all cancer-related mortality.79

In addition to causing premature death, smoking, Smoking, poor diet coupled physical inactivity, and poor nutrition place significant economic pressure on the United States with physical inactivity, and due to increased health care costs and lower alcohol consumption were productivity. Direct medical expenses attributed to the leading “actual” causes of smoking total more than $75 billion per year, and lost productivity is estimated to cost $80 billion per mortality in the United year. 80 Health care costs associated with physical States in 1990 and again in inactivity were an estimated $76 billion in the year 2000. 2000, and poor nutrition was estimated to cost $33 billion in medical costs and $9 billion in lost productivity.81

Physical inactivity and poor eating habits have contributed to an increase in obesity in recent years. Adult obesity rates grew from 15 percent of the population in 1978-80 to 32 percent in 2003-2004.82 For children 6 to 11 years old, obesity rates have increased from 15.1 to 18.8 percent between 1999 and 2004.83 Obese children are about three times more expensive for the health system than average weight children.84

Obesity is a particularly important concern for women who are pregnant or trying to become pregnant. Evidence shows that obesity negatively affects ovulation, fertility, and birth outcomes; and weight loss substantially reduces perinatal costs.85 In one study, costs were $275,000 per live birth before weight loss and $4,600 per live birth after weight loss.86

For most measures, health statistics and behaviors of the Connecticut population are similar to or slightly better than those found in the rest of the country. For example, more than 12 percent of adults in the state report their health as fair or poor, 21 percent of adults did not participate in any leisure time exercise or physical activity in the past 30 days, over 20 percent are obese, and 17 percent are smokers.87

In 2006 state rankings, Connecticut ranked 4th lowest in the percentage of adult smokers.88 Despite our enviable position in the rankings, our costs attributable to smoking are staggering. In 2004 in Connecticut, the medical costs due to smoking were $1.63 billion and lost productivity due to smoking was $1.02 billion. Direct Medicaid costs due to smoking were $430 million.89 12 The Economic Impact of Prevention

The high costs attributable to smoking suggest substantial potential returns for increased investment in tobacco-use prevention. However, Connecticut is the only state in the nation that committed no tobacco settlement money for tobacco prevention programs in fiscal year 2008.90 The CDC recommended minimum FY 2008 State funding for tobacco prevention programs is $21.2 million, and the estimated annual state tobacco revenue (settlement plus excise taxes) is $377.5 million.91

Effective tobacco-use prevention programs have been implemented in other states (e.g., Massachusetts, Vermont, New York, and Montana). Programs directed at reducing the number of children and youth who become smokers have been particularly effective.92,93 Some programs also lead to short-term health cost savings. Specifically, reducing smoking among pregnant women (including teens) reduces smoking-related pregnancy and birth complications (including low birthweight) and related healthcare costs.94,95 Until tobacco-use prevention and cessation are prioritized at the state level, Connecticut will continue to endure increased long-term health costs, lower economic productivity, reduced quality of life, and avoidable mortality—all attributable to smoking.

Connecticut ranks eighth among states in percentage of overweight/obese adults.96 However, the state has not escaped the national trend towards rising obesity rates. Obesity rates in Connecticut rose from 15.1 percent of the population in 1990 to 20.6 percent in 2007.97 The continued growth in obesity in Connecticut is likely to lead to detrimental health effects such as diabetes and hypertension (even among children and adolescents) along with their associated health care costs and productivity losses. In 2003, Connecticut Chronic disease ranked higher than 33 other Seven out of ten deaths in the United States are states for deaths caused from caused by chronic disease.98 In 2003, seven of the most common Connecticut ranked higher than 33 other states for deaths caused from seven of the most chronic diseases. common chronic diseases—cancer, diabetes, heart disease, hypertension, stroke, mental disorders, and pulmonary conditions.99 The economic impact in Connecticut (in treatment expenditures and lost productivity) of these seven chronic diseases was estimated at $16.2 billion in 2003.100 An estimated $1.7 billion in health care costs, lost productivity, and premature mortality were attributed to diabetes in 2002 in Connecticut.101 For lung cancer, Connecticut inpatient hospital charges in 2001 were $44.4 million, or more than $21,000 per hospitalization.102

If trends in disease prevalence continue at current rates, the economic impact of cancer, diabetes, heart disease, hypertension, stroke, mental disorders, and pulmonary conditions is estimated to be $44.5 billion in Connecticut in 2023.103 By making reasonable improvements (i.e., smoking reduction, weight control with improved nutrition, exercise, and early detection of disease) in preventing and managing chronic disease, Connecticut could reduce future economic costs of these diseases by $11.9 billion in 2023.104

13 The Economic Impact of Prevention

Health disparities One of the primary goals of Healthy People 2010 is the elimination of health disparities among different segments of our population. Connecticut’s relatively high rankings among states in many health status measures mask striking health disparities that exist within its borders. Health care and health spending are not distributed uniformly in Connecticut, resulting in severe health disparities by race/ethnicity, income, education, and geographic location. For example, in 2002 cancer incidence was higher for whites than for blacks or Hispanics, but the cancer death rate in Health care and health 2004 was higher for blacks than for whites.105 The spending are not distributed diabetes death rate in 2004 for blacks was more than double the rate for whites.106 uniformly in Connecticut, resulting in severe health Several factors help to explain these disparities. disparities. When diseases such as cancer and diabetes are detected, they are often detected later in the disease trajectory for minority populations, which Greater efforts are needed to is a reflection of poorer access to preventive and develop effective preventive primary care. There are also genetic and biologic factors. For example, breast cancer incidence rates interventions that are lower for African Americans but the tumor specifically focus on types common among African American women minority populations. are different than the tumor types common among white women, and the cancers tend to be at a more advanced stage when recognized. This, along with access to treatment and socioeconomic status contribute to breast cancer survival rates that are lower for African American women.107,108,109 These data suggest that greater efforts are needed to develop effective preventive interventions that specifically focus on minority populations. In fact, the midcourse review of Healthy People 2010 found that no progress had been made in reducing health disparities, despite implementation of various recommended strategies.110

Disparities are also evident in data related to healthy behaviors. In Connecticut, 37 percent of all adults are at a healthy weight and 21 percent of all adults are obese. For the white adult population, 38 percent are at a healthy weight and 20 percent are obese. However, only 25 percent of the black adult population and 24 percent of the Hispanic adult population is at a healthy weight, while 31 percent of black adults and 23 percent of Hispanic adults are obese.111

In Connecticut, poverty is widespread and deeply rooted in urban centers and in pockets of rural areas. In general, population groups with high rates of poverty suffer from poorer health status than population groups with lower rates of poverty. Lower income groups are also more sensitive to the negative effects of cost sharing in regard to receiving health care and preventive services. For example, one study showed that the effect of cost sharing on screening mammography is magnified among women residing in lower income areas. Screening rates decreased 9 percent in one year in health plans that instituted cost sharing compared to screening rates in health plans that did not institute cost sharing.112

14 The Economic Impact of Prevention Connecticut is a relatively small state; however, some of its rural areas are isolated in terms of access to timely care. People in rural areas are less likely to receive preventive care, which may in part explain their higher rates of heart disease, cancer, and diabetes compared to rates for people in urban areas.113 Further, residents in non-urban areas in Connecticut experience 28 percent more premature death than residents in suburban areas.114

Prevention benefits to the state and other employers Total health care spending in Connecticut was over $22 billion in 2004, which was 12.1 percent of the gross state product.115 While quality of clinical care is high in Connecticut, costs are also high compared to other states.116 Additionally, state health rankings occur within the context of a national health system that performs poorly relative to other industrialized nations in regard to cost and outcomes.117,118,119 For example, U.S. Census bureau data shows that 43 countries have life expectancies that exceed the United States, and 40 countries have lower infant mortality.120 If Connecticut were considered a country, it would rank 27th in infant mortality.121

As described above, poor, urban, rural, and minority populations are at a particular disadvantage due to lack of access to health Prevention leads to healthier, care in general and preventive care in more productive employees. particular. For example, the percentage of women who receive prenatal care varies from 78 percent among Hispanics to 92 percent among whites.122 Access to adequate prenatal care is a particular concern in Connecticut’s urban centers. During the period between 1999 and 2001, 10.9 percent of births statewide occurred to mothers with late or no prenatal care. In Hartford, 19.6 percent of births occurred with no or late prenatal care. The equivalent figure in Bridgeport was 19.7 percent; 18.2 percent in New Haven, 19.9 percent in Waterbury, 21.3 percent in New London, and 21.3 percent in New Britain.123 Over 45 percent of the children enrolled in Connecticut’s Medicaid program live in these cities.124 In the Missouri Medicaid program, an analysis of prenatal, newborn, and post- partum costs demonstrated savings of $1.49 for every $1.00 spent on prenatal care.125 Thus, enhancing access to prevention-focused prenatal care in Connecticut’s cities is likely to improve birth outcomes and lower Medicaid costs.

Medicaid, the largest single expense in the Connecticut state budget, is projected to grow from $2.70 billion in fiscal year 2003 to $4.35 billion in fiscal year 2012—an increase of 71 percent.126 While increasing reimbursement to Medicaid providers should improve access to care for the Medicaid-covered population, ensuring that cost-effective, culturally-appropriate preventive services and interventions are prioritized and available will both improve population health and help control costs over the long term.

Prevention has the potential to benefit employers (including state government) in several ways. First, prevention leads to healthier, more productive employees. For example, absenteeism associated with obesity and morbid obesity costs employers an estimated $4.3 billion annually.127 On-the-job work impairment or “presenteeism” is recognized by employers as a major drain on worker productivity. Research shows that the presence of a chronic condition, (e.g., allergies, arthritis, or back and neck disorders) was the most important determinant of work impairment.128 One study estimated the costs to employers of lost productive time (reduced 15 The Economic Impact of Prevention performance at work and work absence) among workers with depression to be $44 billion per year.129 Recent research also suggests that many employers would experience a positive return on investment from outreach and enhanced treatment of depressed workers, not only through increased worker productivity, but also through improved job retention, which reduces hiring and training costs.130

As is the case for most employers, health insurance costs paid by the state for employees, retirees, and Medicaid beneficiaries has increased in recent years.131 While more research is needed to assess the long-term effects, early indications suggest that prevention can lead to reduced health insurance costs. Research involving 46,026 employees from six large employers found that the presence of common modifiable health risks (self-assessment of depression, high stress, high blood glucose levels, being over- or under- weight, tobacco use, high blood pressure, and a sedentary lifestyle) is associated with short-term increases in health expenditures for affected employees.132 Many of these health risks are present in state-covered populations and are amenable to clinical and community preventive services.

In another research project, a large employer eliminated cost sharing for preventive services and increased cost sharing for non-preventive medical services for a group of employees. Preliminary analysis indicates that the benefit change resulted in a five percent reduction in total costs among affected employees, compared with a four percent increase in total costs in the control group.133 While evidence of effectiveness and cost-effectiveness of prevention programs specifically targeted to state-covered populations is sparse, it is reasonable to expect that what works in the private sector will work in the public sector. However, research should be conducted to identify effective programs that can contribute to an evidence base of effective prevention strategies for state employees, retirees, and Medicaid-covered populations.

Being uninsured reduces rates of preventive service use.134,135 In Connecticut, a major portion of the cost of uncompensated care (health care for the uninsured and underinsured) is covered by state funds. Uncompensated care primarily covers costs of diagnosing and treating illness and injury. To the extent that preventive services avoid or mitigate such illness or injury in the uninsured or underinsured, the value of health spending for uncompensated care could be improved. In all likelihood the state is not realizing the economic benefits of prevention for persons covered by uncompensated care funds.

Connecticut has ranked in the top ten in state health rankings since 1990.136 Maintaining and improving the health of state residents in coming years will require investments in prevention, particularly at the population level, that encourage healthy behaviors, reverse or slow growth in rates of chronic diseases, and improve service delivery for underserved populations.

16 The Economic Impact of Prevention Conclusion

The ancient Greeks believed that Asclepius, the god of medicine, had two daughters. One, Panacea, was responsible for treatment, while the other, Hygeia, was responsible for prevention.137 While the ancient Greeks may have viewed prevention and treatment as equally important, the priority in modern medicine in the United States is clearly the treatment of disease.

Treatment is reactionary and largely ignores factors related to poor health until after deleterious effects emerge. On the other hand, prevention is proactive. Effective prevention interventions target the behavior and lifestyle factors that undermine health and provide value for the dollar.

Evidence clearly demonstrates the health benefits and economic value of prevention at all points along its primary-secondary-tertiary continuum and wherever prevention services are delivered, including community settings, health care providers’ offices, in the workplace, or at home. The impact and value is greatest when prevention is implemented at the earliest opportunity, but prevention efforts yield results all along the continuum. For example, tobacco-use prevention is more effective and cost-effective than smoking cessation, but both are important elements of a cost-effective health system. The same argument holds true for numerous conditions, including hypertension, diabetes, and obesity.

U.S. health care spending increased 6.7 percent to $2.1 trillion in 2006, or $7026 per person.138 Health care spending is expected to continue to increase during the next decade, and is estimated to reach $4.3 trillion in 2017, or $13,101 per person.139 The continuing upward spiral of health care costs points to a need to invest in services that reduce lifetime health care spending. A recent analysis of policy options for achieving savings and improving value in health spending noted that reductions in tobacco use and obesity have the potential to save a Prevention is an essential cumulative $474 billion in national health and effective component of expenditures over ten years.140 any evidence-based strategy

Thus, prevention is an essential and effective to improve the value of component of any evidence-based strategy to current health spending, improve the value of current health spending, slow the growth of health slow the growth of health care costs, and ultimately reduce long-term health spending. care costs, and ultimately Additionally, prevention provides reduce long-term health considerable quality of life and functionality spending. benefits and may foster more equitable access to health care for all residents.

17 The Economic Impact of Prevention Appendix I

Healthy People 2010 Healthy People 2010 has two overarching goals:

• to increase quality and years of healthy life • to eliminate health disparities.

These goals are supported by specific objectives in the following focus areas:

1. Access to quality health services 2. Arthritis, osteoporosis, and chronic back conditions 3. Cancer 4. Chronic kidney disease 5. Diabetes 6. Disability and secondary conditions 7. Educational and community-based programs 8. Environmental health 9. Family planning 10. Food safety 11. Health communication 12. Heart disease and stroke 13. HIV 14. Immunization and infectious diseases 15. Injury and violence prevention 16. Maternal, infant, and child health 17. Medical product safety 18. Mental health and mental disorders 19. Nutrition and overweight 20. Occupational safety and health 21. Oral health 22. Physical activity and fitness 23. Public health infrastructure 24. Respiratory diseases 25. Sexually transmitted diseases 26. Substance abuse 27. Tobacco use 28. Vision and hearing

Full achievement of the goals and objectives of Healthy People 2010 depends on a health system that integrates individual health care, population-based public health, and healthy behaviors. The Healthy People initiative envisions prevention efforts that move beyond the traditional medical care system and into neighborhoods, schools, workplaces, and families in which people live their daily lives. These are the environments in which a large portion of prevention occurs.

18 The Economic Impact of Prevention Appendix II Healthy Connecticut 2000 The Healthy Connecticut project was launched in 1994 by the state Department of Public Health. It applies the national goals of Healthy People 2000 to the Connecticut population. The Healthy Connecticut 2000 Final Report was published in 2005 and evaluates the state’s progress toward goals and objectives developed to improve health and functioning of state residents. The report lists 19 priority areas as shown in Table A1. As in Healthy People 2000 and Healthy People 2010, the priority areas of Healthy Connecticut 2000 have a clear emphasis on prevention and health promotion.

Table A1. Healthy Connecticut 2000 Priority Areas Health Promotion Physical Activity and Fitness Nutrition Tobacco Family Planning Violent and Abusive Behaviors Educational and Community-Based Programs Health Protection Unintentional Injuries Occupational Safety and Health Environmental Health Food and Drug Safety Oral Health Preventive Services Maternal and Infant Health Heart Disease and Stroke Cancer Diabetes and Chronic Disabling Conditions HIV Infection Sexually Transmitted Diseases Immunization and Infectious Diseases Surveillance and Data Systems Surveillance and Data Systems

Updates to Healthy Connecticut 2000 document improvement in many of the priority areas listed above. The report also recommends several areas related to prevention and health promotion where future public health efforts will be particularly important in Connecticut. These include: tobacco use; diet, physical activity, and overweight; infectious and vaccine-preventable diseases; pregnancy and childbirth (low birth weight); and environmental health.

19 The Economic Impact of Prevention Appendix III

The U.S. Task Force on Community Preventive Services The Task Force on Community Preventive Services compiled and reviewed existing research to determine the effectiveness of preventive interventions. The effectiveness and economic benefit of several recommended strategies follow.

Changing Risk Behaviors and Addressing Environmental Changes Risk factors and behaviors discussed include tobacco use, physical activity, and the social environment.

Tobacco Use Environmental tobacco smoke is a health hazard.141 The Task Force reviewed studies of activities designed to reduce exposure to environmental tobacco smoke and found strong evidence of the effectiveness of smoking bans and restrictions. Bans and restrictions were found to be effective in reducing exposure to environmental tobacco smoke by 60 percent, in helping reduce cigarette consumption, and in increasing the number of people who quit smoking. Cost-effectiveness analysis was based on a study that modeled the costs and benefits of a ban or restriction of smoking in all nonresidential buildings in the United States. Modeled costs included implementation and enforcement of the ban and construction and maintenance of designated smoking areas. Benefits included medical cost savings, value of lives saved, averted costs of reduced smoking-related fires, and productivity gains. The net benefit to society ranged from $42 to $78 billion.142

Physical Activity The studies reviewed used several approaches to increasing physical activity, including informational campaigns, behavioral and social interventions, and environmental and policy changes. The Task Force found strong evidence of effectiveness of increasing physical activity for several interventions. Only two of the studies analyzed cost-effectiveness. The behavioral intervention that provided strong evidence of effectiveness and cost-effectiveness was an individually-adapted health behavior change program. These programs are tailored to individual interests and teach participants to make moderate-intensity physical activity a part of their daily routines.

The Social Environment The Task Force included early childhood development, access to affordable and safe housing, and culturally competent health care in the social environment. It recommended comprehensive, center-based, early childhood development programs for low income children, because of strong evidence of effectiveness and associated cost-effectiveness. Tenant-based rental assistance programs (e.g., Section 8) were also determined to be effective, but cost- effectiveness data were not available.

Reducing Disease, Injury, and Impairment This part of the report included community preventive services related to cancer, diabetes, vaccine-preventable diseases, oral health, motor vehicle occupant injury, and violence. 20 The Economic Impact of Prevention Economic analyses were found for diabetes, vaccine-preventable diseases, oral health, motor vehicle occupant injury, and violence.

Diabetes The Task Force recommends diabetes disease management based on strong evidence of the effectiveness of 27 studies and cost-effectiveness based on two studies. One of the studies described a program of education for self-management of diabetes in the home. While costs of the intervention program did not differ significantly from traditional care, mean glycated hemoglobin (GHb) levels were 10 percent lower for the intervention group at 24 and 36 months.143

Vaccine preventable diseases The Task Force recommends school-based vaccination programs based on nine studies that demonstrate sufficient evidence of effectiveness. Vaccination programs in schools increase immunization coverage by approximately 58 percentage points.144 One study assessed the cost-effectiveness of British Columbia’s hepatitis B vaccination program in 1994 and 1995. The investigators found that the cost of vaccinating each student was $44, and future health expenditures decreased by $35 per child. When the value of productivity losses is considered, the vaccination program results in cost savings of $75 per child.145

Motor Vehicle Occupant Injury Sobriety checkpoints are used to reduce driving after drinking by increasing drivers’ perceived risk of being caught. Studies have shown that checkpoints reduce fatal and non- fatal injury crashes. An economic evaluation modeled a sobriety checkpoint of one-year in duration for a community with a population of 100,000. The estimated benefit from alcohol-related crashes averted was $7.6 million, while the estimated cost of the intervention was $1.6 million.146

Violence The Task Force recommends early childhood home visitation to prevent violence against children based on strong evidence of effectiveness of several studies, one of which also demonstrated cost-effectiveness. In these programs, parents and children are visited at home during a child’s first two years of life by trained personnel who provide information, support, and training about child health, development, and care. The Task Force reviewed 21 studies and concluded that early childhood home visitation is effective in reducing child maltreatment by approximately 39 percent.147

One study analyzed the cost-effectiveness of an early childhood visitation program, finding that services provided to low-income families resulted in a net benefit to government of $350 per family.148 Costs examined in the study included nurses’ salaries, fringe benefits, travel, and support staff. Benefits included reduced use of government benefits such as AFDC and child protective services and tax revenues from parents returning to work. Costs and benefits in this study were limited to government costs and benefits. If costs and benefits of participants, the health care system, and society at large are taken into account, even greater benefits would be demonstrated, particularly from reduced use of child treatment services through the educational, employment, human services, and criminal justice systems.

21 The Economic Impact of Prevention Appendix IV

The U.S. Preventive Services Task Force The mission of the USPSTF is:

1) to evaluate the benefits of primary and secondary preventive services in apparently healthy persons based on age, sex, and risk factors for disease, and 2) to make recommendations about which preventive services should be incorporated into primary care practice.

The USPSTF recommends that preventive and curative services should be held to the same basic standard of cost-effectiveness. In other words, a preventive service should not be held to a higher cost-effectiveness standard than a treatment service simply because it is not designed to treat a diagnosed health problem. Early identification of disease through screening generally reduces costs of treatment and improves quality of life for individuals who are diagnosed.

Analysts have produced estimates of relative health impact and cost-effectiveness of USPSTF recommendations as well as utilization data. High-ranking services (those services that reduce burden of disease and are cost-effective) with low utilization rates include: tobacco-use screening and brief intervention, screening adults aged 50 and older for colorectal cancer, immunizing adults aged 65 and older against pneumococcal disease, and screening young women for chlamydia.

22 The Economic Impact of Prevention Appendix V

Economic Methods Glossary

Acceptable cost: In an environment of limited resources, the level of cost tolerated by a decision maker or society for delivery of a medical intervention or program.

Cost analysis: A type of economic evaluation in which the costs of a program or intervention are identified or estimated, allowing calculation of unit cost or cost per unit of service.

Cost-benefit analysis (CBA): A type of economic evaluation in which a program’s cost is compared to the program’s benefits for a period of time, expressed in dollars, as an aid in determining the best investment of resources.

Cost-effectiveness analysis (CEA): A type of economic evaluation that seeks to determine the costs and effectiveness of a medical intervention compared to similar alternative interventions to determine the relative degree to which they will obtain the desired health outcome(s).

Cost-effectiveness ratio: The incremental cost of using an intervention to obtain a unit of effectiveness (such as dollars per life-year gained) compared with an alternative such as another treatment or no treatment.

Cost saving: An intervention which costs less and is more effective than an intervention to which it is being compared.

Cost-utility analysis (CUA): A specific type of cost-effectiveness analysis using quality-adjusted life years as the effectiveness endpoint. By convention, cost-utility analyses are often referred to as cost-effectiveness analyses; however not all cost-effectiveness studies use the cost-utility methodology.

Cost-utility ratio: The incremental cost of an intervention to achieve one quality adjusted life year, compared with an alternative intervention.

Direct medical costs: The cost of medical resources consumed, such as physician visits, surgery, medical supplies and hospitalization. These costs are included in the numerator of the cost- effectiveness ratio.

Direct non-medical costs: The cost of non-medical resources such as child care or transportation that are attributable to the treatment (e.g., transportation to a medical appointment). These costs are included in the numerator of the cost-effectiveness ratio.

Discounting: Calculating the present value of future costs and outcomes.

Dominance: "Simple" or "strong" dominance refers to the situation in which an intervention is dominated by the intervention to which it is being compared. This means that the alternative intervention is more effective and less costly than the original intervention.

23 The Economic Impact of Prevention Effectiveness: The extent to which an intervention achieves health improvements, which can be measured in terms of various outcomes such as cases of disease prevented, years of life saved, or quality-adjusted life years saved.

Effectiveness Studies: Formal analyses that assess the effectiveness of specific health interventions delivered in a practice setting or as part of a community demonstration project.

Incremental cost: The difference between the cost of an intervention of interest and the cost of the intervention to which it is being compared.

Incremental cost-effectiveness ratio: The incremental cost of an intervention divided by the incremental effectiveness.

Net costs: The total cost of an intervention, taking into account any savings in medical resources that the intervention may produce (for example, a drug therapy that decreases hospitalization would have a net cost that included the price of the drug, minus the savings in hospitalization).

Quality-adjusted life years (QALYs): A method that assigns a preference weight to each health state, determines the time spent in each state, and estimates life-expectancy as the sum of the products of each preference weight and time spent for each state.

Simulation modeling: Manipulation of a simplified representation of a system intended to promote understanding of the real system. Manipulation generally involves compressing time or space thus enabling one to perceive the interactions that would not otherwise be apparent because of their separation in time or space.

Time costs: The cost of the time a patient incurs while seeking or receiving care.

Adapted from the Tufts-New England Medical Center, Institute for Clinical Research and Health Policy Studies, Center for the Evaluation of Value and Risk in Health Care; Academy Health Glossary of Terms Commonly Used in Health Care, 2004 Edition; and www.systems-thinking.org.

24 The Economic Impact of Prevention

Notes

1 Breslow L. 1990. A health promotion primer for the 1990s. Health Affairs 9(2): 6-21. 2 Rose G. 1985. Sick individuals and sick populations. International Journal of Epidemiology 14(1): 32-38. 3 Please see Appendix I for a full list of Healthy People 2010 focus areas. 4 Office of Disease Prevention and Health Promotion. 2006. Healthy People 2010 Midcourse Review. Available at: http://www.healthypeople.gov/data/midcourse/pdf/ExecutiveSummary.pdf. Accessed January 23, 2008. 5 Keppel K, Bilheimer L, Gurley L. 2007. Improving population health and reducing health care disparities. Health Affairs 26(5): 1281-1292. 6 Please see Appendix II and Table A1 for a full list of Healthy Connecticut 2000 priority areas. 7 Satcher D. 2006. The prevention challenge and opportunity. Health Affairs 25(4): 1009-1011. 8 The Commonwealth Fund Commission on a High Performance Health System. 2006. Why not the best: results from a national scorecard on U.S. health system performance. Available at http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=401577. Accessed February 7, 2008. 9 Ezzati M, Friedman AB, Kulkarni SC, et al. 2008. The reversal of fortunes: trends in county mortality and cross-county mortality disparities in the United States. PLoS Medicine 5(4): e66. 10 The Henry J. Kaiser Family Foundation. 2007. Health Care Spending in the United States and OECD Countries. Available at: http://www.kff.org/insurance/snapshot/chcm010307oth.cfm. Accessed February 7, 2008. 11 Ibid. 12 Nolte E, McKee CM. 2008. Measuring the health of nations: updating an earlier analysis. Health Affairs 27(1): 58-71. 13 Milbank Memorial Fund. 2005. The National Association of State Budget Officers, and The Reforming States Group, 2002-2003 State Health Care Expenditure Report. Available at: http://www.milbank.org/reports/05NASBO/. Accessed November 28, 2006. 14 National Committee for Quality Assurance. 2005. The State of Health Care Quality 2004. Washington, DC: National Committee for Quality Assurance. 15 Haddix AC, Teutsch SM, Corso PS, eds. 2003. Prevention Effectiveness. Oxford University Press: New York, NY. 16 Weinstein MC, Stason WB. 1977. Foundations of cost-effectiveness analysis for health and medical practice. New England Journal of Medicine 296: 716-721. 17 Zaza S, Briss PA, Harris KW, eds. 2005. The Guide to Community Preventive Services: What Works to Promote Health? Task Force on Community Preventive Services. New York, NY: Oxford University Press. 18 Partnership for Prevention. 2007. Preventive care: a national profile on use, disparities, and health benefits. Available at: http://www.prevent.org/content/view/129/72/. Accessed February 7, 2008. 19 Teutsch SM, Murray JF. 1999. Dissecting cost-effectiveness analysis for preventive interventions: a guide for decision makers. American Journal of Managed Care 5(3): 301-305. 20 Ubel PA, Hirth RA, Chernew ME, Fendrick AM. 2003. What is the price of life and why doesn’t it increase at the rate of inflation? Archives of Internal Medicine 163: 1637-1641. 21 World Health Organization. 2008. Threshold values for intervention cost-effectiveness by region. Available at: http://www.who.int/choice/costs/CER_levels/en/print.html. Accessed May 29, 2008. 22 Starfield B, Shi L, Macinko J. 2005. Contribution of primary care to health systems and health. The Milbank Quarterly 83(3): 457-502. 23 Guttmacher Institute. 2006. U.S. teenage pregnancy statistics: national and state trends and trends by race and ethnicity. Available at: http://www.guttmacher.org/pubs/2006/09/12/USTPstats.pdf. Accessed February 6, 2008. 24 Santelli JS, Lindberg LD, Finer LB, et al. 2007. Explaining recent declines in adolescent pregnancy in the United States: the contribution of abstinence and improved contraceptive use. American Journal of Public Health 97(1): 150-156. 25 Zatonski WA, McMichael AJ, Powles JW. 1998. Ecological study of reasons for sharp decline in mortality from ischaemic heart disease in Poland since 1991. British Medical Journal 316: 1047-1051. 26 Bellinger DC, Stiles KM, Needleman HL. 1992. Low-level lead exposure, intelligence and academic achievement: a long-term follow-up study. Pediatrics 90: 855-861. 27 Doessel DP. 1985. Cost-benefit analysis of water fluoridation in Townsville, Australia. Community Dental Oral Epidemiology 13(1): 19-22. 28 Dowell TB. 1976. The economics of fluoridation. British Dental Journal 140(3): 103-106. 25 The Economic Impact of Prevention

29 Nelson W, Swint JM. 1976. Cost-benefit analysis of fluoridation in Houston, Texas. Journal of Public Health Dentistry 36(2): 88-95. 30 Niessen LC, Douglass CW. 1984. Theoretical considerations in applying benefit-cost and cost-effectiveness analyses to preventive dental programs. Journal of Public Health Dentistry 44(4): 156-168. 31 O’Keefe JP. 1994. A case study on the cost effectiveness of water fluoridation. Would fluoridation make economic sense in Montreal today? Ontario Dentistry 71(8): 33-38. 32 Barnett WS. 1996. Lives in the Balance: Age-27 Benefit-Cost Analysis of the High/Scope Perry Preschool Program. Ypsilanti, MI: High/Scope Press. 33 Landrigan PL, Schechter CB, Lipton JM, et al. 2002. Environmental pollutants and disease in American children: estimates of morbidity, mortality, and costs for lead poisoning, asthma, cancer, and developmental disabilities. Environmental Health Perspectives 110: 721-728. 34 World Health Report 2000—Health systems: improving performance, 2000. World Health Organization. Available at http://www.who.int/whr/2000/en/whr00_en.pdf. Accessed October 10, 2006. 35 Mills PR, Kessler RC, Cooper J, et al. 2007. Impact of a health promotion program on employee health risks and work productivity. American Journal of Health Promotion 22(1): 45-53. 36 Bowne DW, Russell ML, Morgan JL, et al. 1984. Reduced disability and health care costs in an industrial fitness program. Journal of Occupational Medicine 26(11): 809-816. 37 Beevis D. 2003. Ergonomics—costs and benefits revisited. Applied Ergonomics 34: 491-496. 38 Hendrick HW. 2003. Determining the cost-benefits of ergonomics projects and factors that lead to their success. Applied Ergonomics 34: 419-427. 39 Lieu TA, Black SB, Ray P, et al. 1997. Computer-generated recall letters for under-immunized children: how cost-effective? Pediatric Infectious Disease Journal 16(1): 28-33. 40 Nexoe J, Kragstrup J, Ronne T. 1997. Impact of postal invitations and user fee on influenza vaccination rates among the elderly. A randomized controlled trial in general practice. Scandinavian Journal of Primary Health Care 15(2): 109-112. 41 Krahn M, Guasparini R, Sherman M, et al. 1998. Costs and cost-effectiveness of a universal, school-based hepatitis vaccination program. American Journal of Public Health 88(11): 1638-1644. 42 Maciosek MV, Coffield AB, Edwards NM, et al. 2006. Priorities among effective clinical preventive services. American Journal of Preventive Medicine 31(1): 52-61. 43 Lieu TA, Ray GT, Black SB, et al. 2000. Projected cost-effectiveness of pneumococcal conjugate vaccination of healthy infants and young children. JAMA 283(11): 1460-1468. 44 Miller TR, Galbraith MS, Lawrence BA. 1998. Costs and benefits of a community sobriety checkpoint program. Journal of Study of Alcohol 59: 462-468. 45 Stuster JW, Blowers PA. 1995. Experimental evaluation of sobriety checkpoint programs. Washington, DC: U.S. Department of Transportation, National Highway Safety Traffic Administration. DOT HS 808 287. 46 Miller TR, Lestina DC, Spicer RS. 1998. Highway crash costs in the United States by driver age, blood alcohol level, victim age, and restraint use. Accident Analysis and Prevention 30(2): 137-150. 47 Murry JP, Stam A, Lastovicka JL. 1993. Evaluating an anti-drinking and driving advertising campaign with a sample survey and time series intervention analysis. Journal of the American Statistical Association 88(421): 50-56. 48 Wasserman J, Manning WG, Newhouse JP, et al. 1991. The effects of excise taxes and regulations on cigarette smoking. Journal of Health Economics 10: 43-64. 49 Secker-Walker RH, Worden JK, Holland RR, et al. 1997. A mass media programme to prevent smoking among adolescents: costs and cost-effectiveness. Tobacco Control 6: 207-212. 50 Mudarri DH. 1994. The costs and benefits of smoking restrictions: an assessment of the Smoke-Free Environment Act of 1993 (H.R. 3434). Government Document 1994: H.R. 3434, April 1994. 51 Olds DL, Henderson Jr. CR, Phelps C, et al. 1993. Effect of prenatal and infancy nurse home visitation on government spending. Medical Care 31(2): 155-174. 52 Bodenheimer TS, Grumbach K. 2005. Understanding Health Policy: A Clinical Approach. New York, NY: Lange Medical Books/McGraw Hill. 53 Maciosek MV, Coffield AB, Edwards NM, et al. 2006. Priorities among effective clinical preventive services. American Journal of Preventive Medicine 31(1): 52-61. 54 Ibid. 55 Bodenheimer T, Berenson RA, Rudolf P. 2007. The primary care-specialty income gap: why it matters. Annals of Internal Medicine 146: 301-306. 56 The most recent guide to recommendations was published in 2006 and is available at: http://www.ahrq.gov/clinic/pocketgd.pdf. Accessed February 7, 2008.

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57 Maciosek MV, Coffield AB, Edwards NM, et al. 2006. Priorities among effective clinical preventive services. American Journal of Preventive Medicine 31(1): 52-61. 58 Additional USPSTF priorities ranked slightly lower in clinical and cost-effectiveness are colorectal cancer screening, hypertension screening, influenza immunization, pneumococcal immunization, problem drinking screening and brief counseling, and vision screening for adults. 59 Unless otherwise noted, the source of the evidence of effectiveness and cost-effectiveness of the listed interventions is: Maciosek MV, Coffield AB, Edwards NM, et al. 2006. Priorities among effective clinical preventive services. American Journal of Preventive Medicine 31(1): 52-61. 60 Curry SJ, Grothaus LC, AcAfee T, et al. 1998. Use and cost effectiveness of smoking-cessation services under four insurance plans in a health maintenance organization. New England Journal of Medicine 339(10): 673-679. 61 Meenan RT, Stevens VJ, Hornbrook MC, et al. 1998. Cost-effectiveness of a hospital-based smoking cessation intervention. Medical Care 36(5): 670-678. 62 Mandelblatt J, Saha S, Teutsch S, et al. 2003. The cost-effectiveness of screening mammography beyond age 65 years: A systematic review for the U.S. preventive services task force. Annals of Internal Medicine 139(10): 835-842. 63 Losina E, Walensky RP, Geller A. 2007. Visual screening for malignant melanoma: A cost-effectiveness analysis. Archives of Dermatology 143: 21-28. 64 Coco, A. 2005. The cost-effectiveness of expanded testing for primary HIV infection. Annals of Family Medicine 3 (5): 391-399. 65 Van den Akker-van Marle ME, Dankert HM, Verkerk PH, et al. 2006. Cost-effectiveness of 4 neonatal screening strategies for cystic fibrosis. Pediatrics 118(3): 896-905. 66 Jekel JF. 2007. Epidemiology, Biostatistics, and Preventive Medicine. Philadelphia, PA: Saunders/Elsevier. 67 Smith SR, Wakefield DB, Cloutier MM. 2007. Relationship between pediatric primary provider visits and acute asthma ED visits. Pediatric Pulmonology 42: 1041-1047. 68 Rich MW, Beckham V, Wittenberg C, Levin CL, Freidland KE, Carney RM. 1995. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. N Engl J Med 333(18):1190-5. 69 Legorreta AP, Leung KM, Berkbigler D, Evans R, Liu X. 2000. Outcomes of a population-based asthma management program: Quality of life, absenteeism, and utilization. Ann Allergy Asthma Immunol 85(1):28- 34. 70 Kelly CS, Morrow AL, Shults J, et al. 2000. Outcomes evaluation of a comprehensive intervention program for asthmatic children enrolled in Medicaid. Pediatrics 105(5): 1029-1035. 71 Karnick P, Margellos-Anast H, Seals G, et al. 2007. The pediatric asthma intervention: a comprehensive cost- effective approach to asthma management in a disadvantaged inner-city community. Journal of Asthma 44: 39-44. 72 Heidenreich PA, Ruggerio CM, Massie BM. 1999. Effect of a home monitoring system on hospitalization and resource use for patients with heart failure. American Heart Journal 138(4):633-640. 73 Dougherty GE, Soderstrom L, Schiffrin A. 1998. An economic evaluation of home care for children with newly diagnosed diabetes: results from a randomized controlled trial. Medical Care 36: 586-598. 74 Chernew ME, Shah MR, Wegh A, et al. 2008. Impact of decreasing copayments on medication adherence within a disease management environment. Health Affairs 27(1): 103-112. 75 Choudhry NK, Avorn J, Antman EM, et al. 2007. Should patients receive secondary prevention medications for free after myocardial infarction? An economic analysis. Health Affairs 26(1): 186-194. 76 Rosen AB, Hamel MB, Weinstein MC, et al. 2005. Cost-effectiveness of full medicare coverage of angiotensin-converting enzyme inhibitors for beneficiaries with diabetes. Annals of Internal Medicine 143(2): 89-99. 77 Reeves MJ, Rafferty AP. 2005. Healthy lifestyle characteristics among adults in the United States, 2000. Archives of Internal Medicine 165:854-857. 78 Mokdad AH, Marks JS, Stroup DF, and Gerberding JL. 2004. Actual causes of death in the United States, 2000. JAMA (291)10:1238-1245. 79 Calle EE, Rodriguez C, Walker-Thurmond K, et al. 2003. Overweight, obesity, and mortality from cancer in a prospectively studied cohort of US adults. New England Journal of Medicine 348: 1625-1638. 80 U.S. Department of Health and Human Services. 2003. The power of prevention: steps to a healthier US: a program and policy perspective. Available at: http://www.healthierus.gov/steps/summit/prevportfolio/Power_Of_Prevention.pdf. Accessed February 7, 2008. 81 Ibid. 27 The Economic Impact of Prevention

82 U.S. Centers for Disease Control and Prevention, National Center on Vital Statistics, Health, United States, 2003 (Atlanta, GA: Centers for Disease Control and Prevention, 2003); and J.S. Schiller et al., “Early release of selected estimates based on data from the January-September 2005 National Health Interview Survey,” National Center for Health Statistics. Available at: http://www.cdc.gov/nchs/nhis.htm. Accessed February 7, 2008. 83 Ogden CL, Carroll MD, Curtin LR et al. 2006. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA 295(13):1549-1555. 84 Thomson Medstat. 2006. Childhood obesity: costs, treatment patterns, disparities in care, and prevalent medical conditions. Available at: http://www.medstat.com/pdfs/childhood_obesity.pdf. Accessed February 7, 2007. 85 Clark AM, Thornley B, Tomlinson L, et al. 1998. Weight loss in obese infertile women results in improvement in reproductive outcome for all forms of fertility treatment. Human Reproduction 13(6): 1502- 1505. 86 Ibid. 87 Centers for Disease Control and Prevention. 2006. Behavioral risk factor surveillance survey: prevalence data. Available at: http://apps.nccd.cdc.gov/brfss/page.asp?cat=XX&yr=2005&state=CT. Accessed April 26, 2007. 88 The Henry J. Kaiser Family Foundation. 2007. State Health Facts, 2006. Available at: http://www.statehealthfacts.org/comparemaptable.jsp?ind=80&cat=2&yr=17&typ=2&o=a&sort=n. Accessed February 7, 2008. 89 Centers for Disease Control and Prevention. 2006. Sustaining state programs for tobacco control: data highlights 2006. Available at: http://www.cdc.gov/tobacco/data_statistics/state_data/data_highlights/2006/2006.htm. Accessed February 5, 2008. 90 The Robert Wood Johnson Foundation. 2007. A broken promise to our children: The 1998 state tobacco settlement nine years later. Available at: http://www.rwjf.org/files/research/brokenpromise2007sml.pdf. Accessed February 7, 2008. 91 Ibid. 92 Siegel M, Biener L. 2000. The impact of an antismoking media campaign on progression to established smoking: results of a longitudinal youth study. American Journal of Public Health 90(3): 380-386. 93 Flynn BS, Worden JK, Secker-Walker RH, et al. 1997. Long-term responses of higher and lower risk youths to smoking prevention interventions. Preventive Medicine 26: 389-394. 94 Lightwood JM, Phibbs CS, Glantz SA. 1999. Short-term health and economic benefits of smoking cessation: low birth weight. Pediatrics 104 (6): 1312-1320. 95 Adams EK, Melvin CL. 1998. Costs of maternal conditions attributable to smoking during pregnancy. American Journal of Preventive Medicine 15 (3): 212-219. 96 The Henry J. Kaiser Foundation. 2006. Statehealthfacts.org. Percent of adults who are overweight or obese, 2006. Available at: http://www.statehealthfacts.org/comparemaptable.jsp?ind=89&cat=2&sub=26&yr=17&typ=2&o=a&sort=n. Accessed April 29, 2008. 97 United Health Foundation. 2007. America’s Health Rankings: A Call to Action for People and Their Communities. Available at: http://www.unitedhealthfoundation.org. Accessed February 7, 2008. 98 Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. 2005. Chronic Disease Overview. Available at: http://www.cdc.gov/nccdphp/overview.htm. Accessed February 5, 2008. 99 DeVol, Ross, Armen Bedroussian. 2007. An unhealthy America: the economic burden of chronic disease. Milken Institute. Available at: http://www.milkeninstitute.org/publications/publications.taf?function=detail&ID=38801018&cat=ResRep. Accessed February 7, 2008. 100 DeVol, Ross, Armen Bedroussian. 2007. An unhealthy America: the economic burden of chronic disease. Milken Institute. Available at: http://www.milkeninstitute.org/publications/publications.taf?function=detail&ID=38801018&cat=ResRep. Accessed February 7, 2008. 101 Connecticut Department of Health. 2005. Connecticut diabetes fact sheet 2005. Available at: http://www.ct.gov/dph/LIB/dph/hisr/pdf/Diabetes.pdf. Accessed February 5, 2008. 102 Connecticut Department of Public Health. 2004. Connecticut resident hospitalizations, 2001. Unpublished data.

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103 DeVol, Ross, Armen Bedroussian. 2007. An unhealthy America: the economic burden of chronic disease. Milken Institute. Available at: http://www.milkeninstitute.org/publications/publications.taf?function=detail&ID=38801018&cat=ResRep. Accessed February 7, 2008.. 104 Ibid. 105 The Henry J. Kaiser Family Foundation. Statehealthfacts.org. Connecticut: health status. Available at: http://www.statehealthfacts.org/profilecat.jsp?rgn=8&cat=2. Accessed February 6, 2008. 106 Ibid. 107 Joslyn SA. 2002. Hormone receptors in breast cancer: racial differences in distribution and survival. Breast Cancer Research and Treatment 73: 45-79. 108 Grann V, Troxel AB, Zpjwalla N, et al. 2006. Regional and racial disparities in breast cancer-specific mortality. Social Science and Medicine 62: 337-347. 109 Du XL, Fang S, Meyer TE. 2008. Impact of treatment and socioeconomic status on racial disparities in survival among older women with breast cancer. American Journal of Clinical Oncology 31(2): 125-132. 110 Keppel K, Bilheimer L, Gurley L. 2007. Improving population health and reducing health care disparities. Health Affairs 26(5): 1281-1292. 111 Centers for Disease Control and Prevention. March 2008. CDC Wonder data; Obesity; Healthy People 2010. Available at http://wonder.cdc.gov/data2010/focus.htm. Accessed April 28, 2008. 112 Trivedi AN, Rakowski W, Ayanian JZ. 2008. Effect of cost sharing on screening mammography in Medicare health plans. New England Journal of Medicine 358(4): 375-383. 113 U.S. Department of Health and Human Services. Healthy People 2010. Available at: http://www.healthypeople.gov/Document/tableofcontents.htm#under. Accessed February 6, 2008. 114 United Health Foundation. 2007. America’s Health Rankings: A Call to Action for People and Their Communities. Available at: http://www.unitedhealthfoundation.org. Accessed February 7, 2008. 115 The Henry J. Kaiser Family Foundation. Statehealthfacts.org. Connecticut: health costs and budgets. Available at: http://www.statehealthfacts.org/cgi- bin/healthfacts.cgi?action=profile&category=At%2dA%2dGlance&subcategory=&topic=&link_category=& link_subcategory=&link_topic=&welcome=0&area=Connecticut. Accessed April 13, 2007. 116 United Health Foundation. 2006. America’s Health Rankings: A Call to Action for People and Their Communities. Available at http://www.unitedhealthfoundation.org. Accessed February 7, 2008. 117 Organisation for Economic Co-operation and Development. 2007. Health at a glance 2007 – OECD indicators. Available at: http://www.oecd.org/document/11/0,3343,en_2825_495642_16502667_1_1_1_1,00.html#HTO. Accessed February 7, 2008. 118 UNICEF Innocenti Research Center. 2007. Child Poverty in Perspective: An Overview of Child Well-Being in Rich Countries. UNICEF: Florence, Italy. 119 Davis K, Schoen C, Schoenbaum SC, et al. 2007. Mirror, mirror on the wall: An international update on the comparative performance of American health care. The Commonwealth Fund. Available at: http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=482678. Accessed February 7, 2008. 120 U.S. Census Bureau. 2007. International data base. Available at http://www.census.gov/ipc/www/idb/. Accessed February 7, 2008. 121 U.S. Census Bureau. 2007. Statistical Abstract of the U.S., State Rankings. Available at http://www.census.gov/compendia/statab/ranks/rank17.htm. 122 Ibid. 123 Child Health and Development Institute of Connecticut, Inc. Community data profiles on young children. Available at: http://www.chdi.org/resources_profile.asp . Accessed February 7, 2008. 124 Ibid. 125 Schramm WF. 1992. Weighing costs and benefits of adequate prenatal care for 12,023 births in Missouri’s Medicaid program, 1988. Public Health Report 107(6): 647-652. 126 Genuerio RL. 2007. Report to the Appropriations Committee and the Finance, Revenue, and Bonding Committee: An Act Concerning Fiscal Accountability of State Government. Office of Policy and Management, State of Connecticut. Available at: http://www.ct.gov/opm/lib/opm/budget/fiscalaccountability/fa_report_11-26-07_final.pdf. Accessed February 7, 2008. 127 Cawley J, Rizzo JA, Haas K. 2007. Occupation-specific absenteeism costs associated with obesity and morbid obesity. Journal of Occupational and Environmental Medicine 49: 1317-1324.

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128 Collins JJ, Baase CM, Sharda CE, et al. 2005. The assessment of chronic health conditions on work performance, absence, and total economic impact for employers. Journal of Occupational and Environmental Medicine 47: 547-557. 129 Stewart WF, Ricci JA, Chee E, et al. 2003. Cost of lost productive work time among US workers with depression. JAMA 289(23): 3135-3144. 130 Wang PS, Simon GE, Avorn J, et al. 2007. Telephone screening, outreach, and care management for depressed workers and impact on clinical and work productivity outcomes: A randomized controlled trial. Journal of the American Medical Association 298(12): 1401-1411. 131 Genuerio RL. 2007. Report to the Appropriations Committee and the Finance, Revenue, and Bonding Committee: An Act Concerning Fiscal Accountability of State Government. Office of Policy and Management, State of Connecticut. Available at: http://www.ct.gov/opm/lib/opm/budget/fiscalaccountability/fa_report_11-26-07_final.pdf. Accessed February 7, 2008. 132 Goetzel RZ, Anderson DR, Whitmer RW, et al. 1998. The relationship between modifiable health risks and health care expenditures: an analysis of the multi-employer HERO health risk and cost database. Journal of Occupational and Environmental Medicine 40(10): 843-854. 133 Busch SH, Barry CL, Vegso SJ, et al. 2006. Effects of a cost-sharing exemption on use of preventive services at one large employer. Health Affairs 25(6): 1529-1536. 134 McWilliams JM et al. 2003. Impact of medicare coverage on basic clinical services for previously uninsured adults. JAMA 290(6): 757-764. 135 Kenkel DS. 1994. The demand for preventive medical care. Applied Economics 26(4): 313-325 136 United Health Foundation. 2006. America’s Health Rankings: A Call to Action for People and Their Communities. Available at: http://www.unitedhealthfoundation.org. Accessed February 7, 2008. 137 Loudon IS, ed. 1997. Western Medicine: An Illustrated History. Oxford: Oxford University Press. 138 Catlin A, Cowan C, Hartman M, et al. 2008. National health spending in 2006: A year of change for prescription drugs. Health Affairs 27(1): 14-29. 139 Keehan S, Sisko A, Truffer C, et al. 2008. Health spending projections through 2017: the baby boom generation is coming to Medicare. Health Affairs – Web Exclusive, February 26, 2008, w145-w155. 140 Schoen C, Guterman S, Shih A, et al. 2007. Bending the curve: Options for achieving savings and improving value in U.S. health spending. The Commonwealth Fund Commission on a High Performance Health System. Available at: http://www.commonwealthfund.org/usr_doc/Schoen_bendingthecurve_1080.pdf?section=4039. Accessed February 7, 2008. 141 Hackshaw AK, Law MR, Wald NJ. 1997. The accumulated evidence on lung cancer and environmental tobacco smoke. BMJ 315: 980-988. 142 Mudarri DH. 1994. The costs and benefits of smoking restrictions: an assessment of the Smoke-Free Environment Act of 1993 (H.R. 3434). Government Document 1994: H.R. 3434, April 1994. 143 Dougherty GE, Soderstrom L, Schiffrin A. 1998. An economic evaluation of home care for children with newly diagnosed diabetes: results from a randomized controlled trial. Medical Care 36: 586-598. 144 See references 167-183 on pages 295-296 of The Guide to Community Preventive Services: What Works to Promote Health? Zaza S, Briss PA, Harris KW, Eds. 145 Krahn M, Guasparini R, Sherman M, et al. 1998. Costs and cost-effectiveness of a universal, school-based hepatitis B vaccination program. American Journal of Public Health 88(11): 1638-1644. 146 Miller TR, Galbraith MS, Lawrence BA. 1998. Costs and benefits of a community sobriety checkpoint program. Journal of Study of Alcohol 59: 462-468. 147 Zaza S, Briss PA, Harris KW, eds. 2005. The Guide to Community Preventive Services: What Works to Promote Health. Oxford University Press: New York, NY. 148 Olds DL, Henderson Jr. CR, Phelps C, et al. 1993. Effect of prenatal and infancy nurse home visitation on government spending. Medical Care 31(2): 155-174.

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